Childbearing Family Nursing

• First
• period of 8 to 12 hours marked by the onset of regular contractions of the uterus with full dilation of the cervix and the appearance of a small amount of blood-tinged mucus.
• *Latent
• *Active
• *Transition
• Second
• full dilation of the cervix to delivery of the fetus.cervical opening is 10 cm.

Breathing Patterns

RELIEVE BACKACHE

OTHER EFFECTIVE COMFORT MEASURES

• BEARING
• DOWN TECHNIQUES

POSITIONS

• “laboring down” or push only with the urge

• directed pushing or valsalva pushing

• open-glottis pushing

• OXYGEN: Lungs sounds and respiratory rate for mother
• every 4 hours. More frequently per protocol if she had intrathecal narcotics.

• CARDIAC: Rate and rhythm for mother every 4
• hours. Presence or absence of murmurs.

• NEUROMUSCULAR: Temperature for mother every 4 hours. Assess
• anesthesia regression. Dermatomes. Examine epidural/spinal site for fluid loss.
• Check dressing.

• ASSESSMENTS
• WILL BE DONE AND CHARTED EVERY 4
• HOURS ON BOTH MOTHER AND BABY. FOR A
• MOTHER WHO IS A NEW ADMISSION
• ASSESSMENTS ARE DONE EVERY 2 HOURS. THE FIRST
• THREE TIMES A NEW POSTPARTUM PATIENT VOIDS IT MUST BE MEASURED AND
• RECORDED.

• 1. In addition to a visual and detailed physical
• assessment of the breast, if the mother has chosen to breastfeed, be sure to evaluate
• position, latch-on and other aspects of breastfeeding in your assessment.

• • Evaluate for discomfort or
• tenderness, especially during feedings

• • Evaluate nipples/breasts
• for soreness, symmetry, cracks, inverted/everted

redness, streaking

• • Degree of softness = soft,
• filling, or firm

• • Instruct nursing moms in
• breast care, positioning and comfort, length of time to breast

• feed, hygiene (wash breasts with warm water,
• no soap)

• 2. Bottle-feeding mothers should be evaluated for
• breast discomfort and they should be encouraged to wear a supportive bra for
• comfort. Palpation to assess breast fullness should be light to avoid breast
• stimulation.

UTERUS

1. Client low fowlers

2. Palpate uterine fundus: put one hand at symphysisto stabilize; while the other

• hand
• massages fundus until firm and clots expressed.

• • Fundus should be midline
• and firm

• 1st 24 hrs near umbilicus

• • recedes 1 cm/day
• postpartum

3. Document as

• U/1 1 cm below umbilicus

• 1/U 1 cm above umbilicus

• • Midline or deviation from
• midline

• Tone--firm, boggy

• 4.
• If administering Pitocin, give at ordered rate
• and NEVER IV-push

• Oxytocin
• High Alert Medication

• •
• Stimulates uterine smooth muscle, producing uterine contractions similar to
• those in spontaneous labor

• •
• Has vasopressor and antidiuretic effects

• 5. Pitocin
• can cause increase in BP

• 6. Teach
• patient to assess and massage her own fundus

• 7. Administer
• pain meds for uterine contraction or “afterbirth pains”

BLADDER

(May void copiously the first few days after delivery)

1. Palpate bladder

• • Empty, shouldn’t be able
• to feel above symphysis

• • If full, prevents uterine
• contractions

• • When distended will rise
• up to right

• Increases vaginal bleeding

2. Observe for infection

• • Infrequent or insufficient
• urination

• Discomfort or burning

• Foul smelling

• • Note frequency, dysuria,
• retention

Causes: perineal edema

• Lacerations

• • Long labor without voiding
• regularly

BOWELS

1. Abdomen should be soft and not distended

• 2. Auscultate bowel sounds, passing gas, and passing
• of stool.

3. Document - 1st BM usually 2 days postpartum

• 4. NO enema or digital exam if pt. has 3rd or 4th
• degree lacerations!

LOCHIA

• Assess to prevent hemorrhage and shock. Report saturation of OB-Pad in 2 hours or
• less.

1. Inspect for color, amount, odor, presence of clots

• Color

• • Days 1-4: rubra: red or
• brownish red

• • Days 4-10: serosa (in some
• women my last through 27 days); thin and red; composed of serum and blood.

• • Days 10-3rd to 6th
• week: alba: whitish yellow

• • Color shouldn’t revert to
• earlier stage.

• Amount

• • slight or scant - 4
• pads/day

• moderate - 4 to 8 pads/day

• • heavy - 8 pads (woman’s
• changing habits influences)

• 1cc = 1 gm

• • Odor - earthy, faintly
• musky; foul may indicate infection

• • Clots - few small in 1st
• few days. Document any clots present

EPISIOTOMY/PERINEUM

• 1. Position
• on affected side, instruct to flex upper leg; gently lift upper buttock;
• episiotomy will be midline, right or left.

• 2. Inspect
• for:

• Irritation, approximation of
• sutures, white line length of episiotomy, ecchymosis,

• s/s of infection, s/s
• perineal hematoma, tenderness, swelling, severe, intractable pain, edema,
• discharge, perineal discoloration, hemorrhoids

• 3. Employ
• comfort measures

• Moist heat - Sitz bath

• • if shared tub: clean, rinse,
• dry tub and pad with towel before filling

• • disposable - place under
• toilet seat with overflow valve to back

• • fill 1/3 to ½ full with
• warm water after connecting bag to groove at front

• • teach to tighten gluteal
• muscles until seated, then relax

• • check q 15 min. - assess
• pulse as needed, make sure call bell is in reach

• Ice pack

• • apply covered pack to
• perineum (apply immediately after birth and continuously over 24-36 hrs to
• prevent edema and for comfort

• • Administer analgesics,
• Tucks (witch hazel swipes) topical sprays and ointments

• Assess
• for thrombophlebitis:

1.Assess for:

• Legs symmetrical? Equally
• warm? Ask pt about let pain at rest or with ambulation. Ask

• pt to Flex feet to assess
• for pain.

2. Assess for:

• Tenderness, nodules, warm
• areas, discoloration or varicosities

• 1. Help
• prevent thrombophlebitis:

• • early ambulation - teach
• to request assistance at first; may become light-headed or faint

• ·
• If on bedrest, teach patient stretches and
• range of motion exercises

• • avoid constricting
• clothing and crossed legs

1. Assess phase

• • Taking in - immediately
• after birth

• sleeps

• depends on others

• • relives events surrounding
• birth

• • Taking hold - few days
• postpartum

• • begins to gain control of
• body functions

• • becomes preoccupied with
• present

• • is concerned about her
• health, baby’s health, her ability to care for baby

• • show independence in
• self-care and newborn care

• Letting go

• • re-establishes
• relationships with others

• 2. May feel vulnerable, have mood swings, insomnia,
• irritability (baby blues)

• 3. Causes: hormonal changes, role definition,
• discomfort, fatigue

• Assess C-section incision; reinforce dressing as
• needed; remove sutures or clips as ordered. Degree of muscle stretching or
• presence of diastasis recti and linea negra.

Assess and Document following:

R - redness

E - edema

E - ecchymosis

D - discharge

A - approximated edges

– Be sure to follow individual hospital procedure.

• 1. Check BP, P q 15 min. Immediately x 4 or more until
• stable

2. Then q 30 min, x 2

3. When stable check VS q shift and PRN

• 1. Assess
• fluid intake. Encourage frequent intake
• to quench thirst.

• 2. Assess
• frequency, consistency, and amount of nutrient intake.

• 3. Determine
• if patient is taking prenatal vitamins and iron daily.

Newborn

• Baby Temperature: below 97.7 F (36.5C) OR above 98.9 F (37.2 C)

• Respirations: below 30 OR above 60

• Pulse: below 100 OR above 160

• Glucose: below 45mg/dl OR above 150 mg/dl

• • Has not voided or stooled on your
• shift

• Bilirubin above 10 mg/dl

• orange-yellow
• pigment of bile, formed principally by the breakdown of hemoglobin in red blood
• cells after termination of their normal lifespan. Normal
• levels of total bilirubin are 0.1 to 1 mg/dl

• Bleeding at circumcision

Mother

• • Mom’s fundus above the umbilicus or
• deviated from the midline

• Palpable bladder

• No void in past 4 hours

• • Saturating a peripad in 2 hours or less
• (faster than 2 hours)

Neurological


ENT


Pulmonary


Cardiovascular


GI/GU

Integumentary/Skeletal


Reflexes

• Anterior fontanel – flat, soft, full, tense,
• sunken, bulging

Sutures – approximated, separate, overlapping

• Motor behavior –
• coordinated, symmetrical. asymmetrical, well-flexed, some flexion,

lethargic

• Tone – normal, hypertonic,
• hypotonic

• Activity – Alert, crying,
• active, jittery, lethargic, quiet, sleeping, easily soothed

• Cry – Normal, high
• pitched, weak, hoarse

• Head – symmetrical, round,
• molded

• Caput – left, right,
• parietal, occipital

• Cephalohematoma – left,
• right, parietal, occipital

Aricular – pit

• Eyes – clear, discharge, right, left hemorrhages,
• periobital edema

Ears – symmetrical, absent, tag

Nares – patent

Palate – complete, incomplete

• Suck/Swallow – normal, coordinated, weak, absent,
• inefficient

• Chest wall expansion – bilateral and equal,
• asymmetrical

• Respiratory effort –
• unlabored, nasal flaring, grunting, shallow, apnea, tachypnea, no spontaneous
• respirations

Retractions – none, mild, moderate, marked

• Breath sounds – clear,
• bilateral, equal, right, left, absent, coarse, moist, rales, rhonchi, stridor

• Secretions suctioned –
• none, bulb, wall, small amount, moderate amount, large amount, clear, yellow,
• green, bloody, thick, thin

• Circulation/color – pink,
• dusky, jaundiced, pale, acrocyanosis, mottled, circumoral cyanosis, mottled,
• ruddy

Capillary refill - < 3 seconds, > 3 seconds

• Heart Sounds – regular, irregular, distant, no
• audible murmur, soft murmur, loud murmur

• Pulses – palpable/equal x4, bounding, equal,
• unequal, absent, weak

Skin turger – rapid rebound

• Edema – absent, generalized, moderate, severe,
• specific area

• Cord exam –
• number of vessels (3 expected) meconium stained, no abnormalities

• Abdomen – soft, distended,
• firm, flat, rounded, bowel sounds present/absent, hypoactive, hyperactive. Infant
• feeding – breast, bottle, D10W, D5 W, water, taken well, fair, poorly, nipple, cup, dropper, oral gavage,

• Anus – patent, visually
• assessed, meconium passed, unable to assess

• Genitals – normal for
• Gestational age, edematous, testes descended R/L, testes not palpable,
• epispadius, hypospadius, vaginal tag, vaginal discharge, pseudomenses

• Bagged for Urine specimen
• – limited prenatal care, history of maternal drug use, positive maternal
• toxicology screen, maternal temperature

Extremities – Moves all extremities, full ROM

• Gluteal folds – symmetrical, asymmetrical, knees
• even

• Skin integrity – intact, forceps marks, facial
• bruising, caput, Cephalohematoma, laceration/puncture

• Skin appearance – vernix, milia, peeling, meconium
• staining, rash, petechiae, bruising, lesions

• Birth marks – Mongolian sports, storks bite, nevi,
• note noted,

• Spine – straight and intact, hair tufts, pilonidal
• dimple

• Other physical
• findings – no anomalies noted, skin tags, webbed digits, simian

Grasp reflex – present/absent

Moro reflex – present/absent

• elicited by a sudden
• loud noise, normal response
• consists of flexion of the legs, an embracing posture of the arms, and usually
• a brief cry

Rooting reflex – present/absent/weak

Gag reflex – present, hypo or hyperactive

Blink reflex – present, absent, unable to assess

• Pulse
• 100–160 bpm
• During sleep as low as 80 bpm; if
• crying, up to 180 bpm
• Apical pulse counted for 1 full minute

• Blood Pressure
• 80–60/45–40 mm Hg at birth
• 100/50 mm Hg at day 10

• Respirations
• 30–60 respirations/minute
• Predominantly diaphragmatic but
• synchronous with abdominal
• movements
• Respirations are counted for 1 full minute

• Temperature
• Normal range: 36.5C–37.2C
• (97.7F – 98.9F)
• Axillary: 36.5C–37.2C (97.7F – 98.9F)
• Skin: 36C–36.5C (96.8F – 97.7F)
• Rectal: 36.6C–37.2C (97.8F – 99F)

• Instruction:
• Performs NIPS score with VS, immediately before and 30 min after painful
• procedures.

• Documents NIPS score in the
• medical record with vital signs Intervenes for NIPS score of 2
• or more.

Interventions include:

a. Reposition (place prone or side-lying

• b. Wrap and swaddle in warm blanket (provide
• intrauterine-like support)

c. Support skin-to-skin or kangaroo care

• d. Reduce stimulation (environment, dim lights,
• quiet voice)

e. Hold and rock in vertical position

f. Light Massage or stroking (avoid area of pain)

g. Put to breast or feed as appropriate

• h. Pacifier (if provided by the parent(s) and per
• their consent)

i. Oral sucrose as ordered per MD

3. Limitations:

• • A falsely low score may be seen in an infant who is too ill to
• respond or who is receiving a paralyzing

agent.

• FEEDING
• DIAPERING
• WHEN TO CALL THE BABY’S DOCTOR
• SAFETY
• ENVIRONMENTS
• BREASTS
• ABDOMEN:
• NUTRITION:
• PERINEUM:
• EPISIOTOMY
• BOWELS

• – Do NOT let the
• baby sleep longer than 4 hours (during the day) between feedings for the first
• 6 weeks.

• A. If
• breastfeeding teach to feed as often as baby desires. Do not go longer than 3
• hours during day time and or 4 hours at night without attempting to feed.

• B. Frequency
• and amount if bottle feeding (Don’t
• teach to breast feeding Mom)

• C. Positioning/Burping
• (Teach to ALL Moms)

• 1. Position
• in football, cradle, cross-cradle or side-lying positions for breastfeeding.
• Maintain proper support for head and neck and straight body alignment. If
• bottle-feeding, hold baby close and in semi-sitting position for feedings. Never prop a bottle or leave a baby
• unattended for feedings. Do not bottle
• feed a baby in an infant seat. Support
• head well.

• 2. After
• a feeding, always place the baby on its back for sleeping.

3. Burping

• 4. Breastfed
• babies do not have to be burped routinely.

• a. Breastfed
• babies do not have to be burped routinely.

• b. Done
• in 3 positions

• 1) Over
• the shoulder

• 2) Across
• the lap

• 3) Sitting
• with chin supported

• c. If
• the baby has been crying it might be necessary to burp the baby before feeding.

• d. Burp
• the baby when sucking slows down or stops or after ½ to 1 oz for newborns.

D. Preparation/Storage

• 1. Be
• sure to check the type of formula you have and read the instructions for

preparation.

• 2. There
• are 4 forms of formula

• a. Concentrated
• (liquid): Must add water

b. Powdered: Must add water

• c. Ready
• to use: Place required amount in bottle

• d. Prepackaged
• Ready to Use; Open and serve

• 3. Store
• all prepared formulas in the refrigerator.
• NEVER save formula left in a bottle.
• Throw it away. Change liners or wash bottles in warm soapy water after
• feedings.

• A. First
• five days equals a minimum of 1 wet diaper per day of life. Then, the baby is
• getting enough to eat if it voids 6 – 8 times/day.

• B. Check
• diapers when baby wakes up and before putting baby to bed.

• C. Clean
• diaper area with warm water when changing diaper. Use a mild soap and water if stool is
• present.

• D. Wipe
• a female’s perineal area from front to back and be sure to clean in the folds.

E. Stools

• 1. First
• 2 days – Meconium stools – Dark green-black, thick, sticky

• 2. About
• day 3; greenish to yellow green

• 3. End
• of first week; yellowish

• a. Breastfed
• stools – loose, non-smelly

• b. Bottle
• fed stools – formed with odor

• Should have at least one stool per day. Don’t
• place diaper over u

• A. If
• you have trouble getting the baby to wake up.

• B. An
• axillary (under the arm pit) temperature above 99 degrees (teach how to do).

• C. Vomiting
• – spitting up a large part or all of a feeding two or more times.

• D. Diarrhea
• – Three or more green, liquid stools (Stools have a water ring around them).

• E. Refusing
• to eat two feedings in a row.

• F. Reddening
• around the cord area or a bad smell from the cord.

• A. No
• tub bath for baby until the cord is dry and falls off – approximately 7 – 10
• days.

• B. Baby
• does not need a complete bath every day – may just wash face and diaper area.

• C. Be
• sure to have clean clothes, diapers, towels, soap, and water ready before
• starting the bath.

• D. Room
• and water should be warm.

• E. Make
• sure that the diaper is secured underneath the cord until the cord has dried
• and fallen off. Cleanse with soap and water only if urine or feces get on cord.

F. Don’t place diaper over umbilical cord

• A. Do
• not leave the baby on a bed or couch without adult supervision.

• B. Babies
• should be on their back for sleep, but may play supervised while on their
• tummy.

• C. Car
• seats are required by law – those should be secured carefully before starting
• the car. Practice with the car sear
• before picking the baby up from the hospital.

• D. Have
• Mom and/or Dad demonstrate the use of the bulb syringe and tell you what to do
• for choking (flip the baby over and give back blows/chest thrusts).

• A.
• Crying – the baby may cry frequently – they usually have a fussy period of
• approximately two hours
• each day. Pick the baby up and comfort
• it. Be sure the baby is not hungry or
• wet. The baby may need to suck and a pacifier is good for this
• after the first 3-4 weeks if breastfeeding,
• anytime if bottle-feeding.

• B. Dress
• the baby like the warmest person in the family dresses. Do not over dress the baby.
• This can make them too hot.

• A. Stages
• of milk production:

1. Colostrum: first 2 – 3 days

• 2. Transitional
• milk begins by approx 3- 5 days after
• birth

• a.
• Continues to change in composition for about 10
• days

• 3. Mature
• milk is established by approx 2 weeks

• B. The
• “let down” reflex; what it is and how to facilitate it

C. Engorgement

• 1. Fluid
• build-up usually 2 – 3 days after delivering and 24 hours before milk comes in

• 2. How
• and why it occurs

• 3. How
• to minimize it

• D. Importance
• of wearing bra

• 1. For
• comfort

• 2. To
• decrease engorgement and tenderness

• E. Manual
• expression of milk or colostrum

• F. Nipple
• hygiene – Do not wash with soap

• G. Use
• of lanolin on breasts/nipples

• H. Signs
• of possible breast infection and actions to treat.

• 1. Pain,
• warm, hard, redden area

• 2. Fever,
• feeling ill

• 3. Change
• baby’s nursing position

• 4. Increase
• frequency of nursing

• 5. Call
• provider

• A. Stages
• of milk production:

1. Colostrum: first 2 – 3 days

• 2. Transitional
• milk begins by approx 3- 5 days after
• birth

• a.
• Continues to change in composition for about 10
• days

• 3. Mature
• milk is established by approx 2 weeks

• B. The
• “let down” reflex; what it is and how to facilitate it

C. Engorgement

• 1. Fluid
• build-up usually 2 – 3 days after delivering and 24 hours before milk comes in

• 2. How
• and why it occurs

• 3. How
• to minimize it

• D. Importance
• of wearing bra

• 1. For
• comfort

• 2. To
• decrease engorgement and tenderness

• E. Manual
• expression of milk or colostrum

• F. Nipple
• hygiene – Do not wash with soap

• G. Use
• of lanolin on breasts/nipples

• H. Signs
• of possible breast infection and actions to treat.

• 1. Pain,
• warm, hard, redden area

• 2. Fever,
• feeling ill

• 3. Change
• baby’s nursing position

• 4. Increase
• frequency of nursing

• 5. Call
• provider

• A. Fundus
• is palpated after delivery to check for position change from bleeding or full
• bladder

• B. It
• hurts when palpated (touched) because it is a sore muscle

• C. Normal
• progression of uterus from abdominal organ to pelvic organ after delivery

• D. Cause
• and duration of “after birth pains”

• E. Importance
• of complete bladder emptying

• F. Measures
• to facilitate bladder emptying:

• 1. Squatting
• or standing to void

• 2. Sound
• of water running

• 3. Voiding
• in a sitz bath

• 4. Relaxation
• techniques

• 5. Pouring
• water over perineal area

• A. You
• may continue to take prenatal vitamins, iron, and folic acid while
• breastfeeding and during all childbearing years but confirm recommendation with
• PCP.

• B. If
• lactating, increase caloric intake by 200-500 calories per day for a singleton
• delivery and double this for a twin pregnancy.

• C. If
• not lactating can return to pre-pregnant diet and calories per day.

• D. Continue
• to drink a minimum of 6-10 eight ounce glasses of water or non-caffeinated and
• non-carbonated fluids per day to quince thirst. Additional fluid intake does
• not increase breast milk production.

• E. Drinking
• alcohol is not recommended. If lactating, breastfeed or pump, then have
• alcoholic drink so that the majority can be metabolized by maternal system
• prior to next feeding time. Adult
• metabolism of alcohol is approximately 1 ounce in 2 hours. Mothers’ breastfeeding
• premature or ill infants should avoid alcohol entirely until her infant is
• healthy. Chronic or heavy consumers of alcohol should not breastfeed.

• A. Hygiene
• for perineal area

• 1. Change
• pads every time you void

• 2. Use
• peri-bottle to wash with after each void

• 3. Cleanse
• perineum from vulva towards anus

• 4. Put
• on peri-pad from front to back and remove it the same way

• B. Length
• of time to expect lochia discharge after delivery:

• 1. 1st
• – 3rd days – Rubra

• 3rd – 7th
• days – Serosa

• 7th day – 3rd
• week – Alba

• A. Need to report to M.D. if lochia has foul odor
• or if changes from whitish to bright red

• B. When
• sexual intercourse can be resumed. Some
• of the factors influencing this are:

• 1. Degree
• of perineal tenderness

• 2. Length
• of time of lochia discharge

• 3. Healing
• of placental site

• 4. Preference
• of couple

• A. Kegal’s
• exercises to promote healing, to decrease swelling and to increase circulation
• to the area

• B. Comfort
• measures: ice packs initially after
• delivery up to 24 hrs, heat later; sitz bath

• C. Use
• of local anesthetic sprays, creams or witch hazel pads (if ordered)

• A. Reassure
• that having bowel movement will not cause damage to episiotomy

• B. Fluid
• and dietary measures to combat constipation

• C. Proper
• position while at toilet (leaning back with feet elevated on a foot stool)
• helps to relax anal sphincters

• D. Use
• of cold compresses or witch hazel if ordered for hemorrhoids

• E. Use
• of warm sitz baths if ordered.